Assignment 4_Healthcare Case Analysis_Wallace_M
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Assignment 4: Health Care Analysis
Michele Wallace
University of Maryland Global Campus
HMGT 327: 6381 Legal and Ethical Issues in Health Care
Professor Roxanne Zaghab
October 7, 2023
Three Legal/Ethical Issues
1.
Advance Directives
2.
Surrogate Decision-Making
3.
Informed Consent
Legal/Ethical Issue 1: Advance Directives
Advance directives are a legally binding document that is drafted while a patient is competent to make decisions regarding their medical treatment in the event of incapacity (UMGC, 2023). Also known as a living will, it includes the patient’s personal decisions about end-of-life treatments, resuscitation, and organ donations, however, there are state variations on the definitions surrounding restrictions and decision-making authority. The case study provided indicated the couple drew up a living will one year prior to the husband being incapacitated with a severe brain injury and dependent on ventilator support. The exact specifications of the living will are not spelled out, however, the husband indicated he did not want ventilator support or any
other artificial life support in the event of permanent unconsciousness or terminality. The living will and the diagnosis provided by the treating physician both indicate the patient being in a permanent unconscious condition, which validates authority to withdraw life support.
Legal and ethical implications revolve around respecting and individual’s rights and autonomy to
freely choose what they want and make their own choices, and the duty to respect other’s right. The legal argument for using the living will is the ethical principle of autonomy, in which healthcare providers should ensure the patient’s wishes are honored. Although advance directives can be helpful in choosing the appropriate medical treatment based on the patient’s wishes, challenges arise when there are disputes among family members such as this case where 2
the surrogate/spouse doesn’t believe it applies to her husband’s condition (UMGC, 2023). Therefore, healthcare providers must follow their state laws to address these complexities.
Legal/Ethical Issue 2: Surrogate Decision-Making
The surrogate decision-maker, or in some cases called the “health-agent” is an individual appointed to make health care or legal decisions on behalf of another person when that person is deemed temporarily or permanently incapacitated (UMGC, 2023). In the case provided, the surrogate decision-maker is the patient’s spouse, and the law generally assumes legal relatives are most appropriately appointed (UMGC, 2023). In this case, the wife must use substituted judgement, which is a decision that may differ from the way she feels if the situation were reversed, and she was the patient (UMGC, 2023). However, we learn in this case the wife does not feel the living will was intended to be used in this situation. Ethical implications with these types of conflict must ensure the best interest of the patient. Given surrogacy laws vary by state, if the patient’s quality of life is negatively impacted by a surrogate’s decision, healthcare providers could be left with the difficult legal decision to defer the decision-making authority to another relative, as in this case with the adult children. Legal/Ethical Issue 3: Informed Consent
Informed consent is the legal and ethical standards healthcare providers adhere to provide to the patient (or legal surrogate) to grant permission before a service can be delivered. Only after the physician has explained and noted the medical matter, the consent is then signed (Showalter, 2020). Although informed consent was not granted by the actual patient at the time the permanently unconscious diagnosis was conveyed to the wife by the treating physician, one can infer the living will justifies withdrawing life sustaining care. The wife was advised her husband
would not regain normal brain function and, in this case, the living will should be honored to 3
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protect her husband’s autonomous decision. In the case of refusal to consent to the requested treatment or recommended withdrawal of life supporting by the surrogate, the healthcare provider should not be held liable for a refuted informed consent discussion.
Handling of Legal/Ethical Issue #1 – Advance Directives
As a healthcare provider dealing with patients who have advance directives, I would incorporate physician consultations to review and fully understand their decisions, choices, and rights to proposed treatments. Additionally, given advance directives are to dictate your wishes and rights
should you be deemed incapacitated to do so, ensure your selected health agent or surrogate’s decisions reflect and respect your own values on life sustaining treatments. Adding this step will
help patients fully understand their rights and allow their personal physicians to answer questions
to help with their decisions. The Rights Approach is the ethical philosophy I would incorporate based on a human’s fundamental moral right to make choices about their life, and have those rights respected (UMGC, 2023). As a surrogate in this case, I would have to apply substituted judgement and suppress my own beliefs, emotions and feelings and make the choice my husband, the patient, would have wanted. As the patient’s health care worker/provider, I would need to adhere to similar standards. I am morally responsible to uphold my professional obligations and honor the patient’s documented wishes, respecting his autonomy, and as difficult as it may be, ethically withdraw all life-sustaining treatments.
Handling of Legal/Ethical Issue #2 – Surrogate Decision-Making
In the case provided, the wife of the patient does not feel the living will was intended to be used in her husband’s situation and is refusing to honor his wishes. There are direct conflicts and risks in these situations where feelings and emotions supersede the legal authority of a surrogate. 4
As a healthcare provider, I would meet not only with the appointed surrogate, but engage all family members, and legal counsel to help intervene in making tough decisions. Proactively, as a healthcare provider, I would encourage multiple health agents/surrogates be appointed at the time the advance directive is created to ensure emotional stability during decision making. As a treatment team, our responsibility as health care workers will be to always advocate on behalf of the patient’s autonomy and respect their wishes. We will also have an obligation to be transparent, therefore, by including an ethics committee, together we can communicate and help the family understand the moral and ethical discomfort of the patient to help guide their decision in support of the living will. Albeit the treatment team in this scenario did ethically provide the wife more time to be supported in grief and accept the gravity of her husband’s condition, she still did not withdraw life supporting treatment. As difficult as this situation is, the Utilitarian Approach is a great ethical philosophy approach I would explore to reduce further harm and respect the patient’s wishes (UMGC, 2023). Although
writing this paper I can indicate this is the approach I would take, being in this situation will most likely yield a different decision. This is a complex and difficult decision. I recently drafted
an advance directive for my stepfather as his health started declining after he suffered a stroke three years ago. Like this case, my stepfather has indicated he does not want to be kept alive by artificial life-saving measures. The challenge will be, however, like this scenario, his adult children will want him to be kept alive regardless of the gravity of the situation.
Handling of Legal/Ethical Issue #3 – Informed Consent
The decisions to withdraw life sustaining treatment should solely be based on the patient’s living
will in this case, as that is evidence of the patient’s preference. It is not unethical to discontinue life sustaining medical treatment in direct correlation with documented preference. Informed 5
consent was provided to the patient’s wife in terms of a diagnosis, the risks, prognosis with or without treatment, and probable course of recovery and she still decide to refute withdrawing the ventilator. Having exhausted all measures, as a healthcare team, we will pull in an interdisciplinary team of clinicians with social workers to help evaluate the wife’s mental capacity and provide grief counseling. Research provided suggests that a third of surrogates have significant prolonged negative psychological experiences in making end of life decisions for family members. Offering techniques to surrogates to determine how to die a “good death” may help them look at letting go from a different perspective.
From an ethical philosophy perspective for informed consent, I would consider the Virtue Lens as it provides our habits that inform the disposition of our character. Virtue ethics asks the soul-
searching question of any action of, “What kind of person will I become if I do this?” (UMGC, 2023). This is an important question especially when dealing with the fate of a loved one’s life. I think incorporating this ethical philosophy will help eliminate ethical challenges in making end of life decisions.
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References:
Showalter, S. (2020).
The law of healthcare administration. (9th ed.).
Health Administration Press.
University of Maryland Global Campus. (2023). Relationships: I. Clinical Ethics, Law & Risk Management. Document posted in HMGT 372 online classroom, https://learn.umgc.edu
University of Maryland Global Campus. (2023). A Framework for Thinking Ethically. Document posted in HMGT 372 online classroom, https://learn.umgc.edu
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